42 CFR 1001.1901 - Scope and effect of exclusion.
(a)Scope of exclusion. Exclusions of individuals and entities under this title will be from
(b)Effect of exclusion on excluded individuals and entities.
(1) Unless and until an individual or entity is reinstated into the
(i) By an excluded individual or entity; or
(ii) At the medical direction or on the prescription of a physician or an authorized individual who is excluded when the person furnishing such item or service knew, or had reason to know, of the exclusion.
(2) This section applies regardless of whether an individual or entity has obtained a program provider number or equivalent, either as an individual or as a member of a group, prior to being reinstated.
(4) An excluded individual or entity that submits, or causes to be submitted, claims for items or services furnished during the exclusion period is subject to civil money penalty liability under section 1128A(a)(1)(D) of the Act and criminal liability under section 1128B(a)(3) of the Act and other provisions. In addition, submitting claims, or causing claims to be submitted or payments to be made, for items or services furnished, ordered, or prescribed, including administrative and management services or salary, may serve as the basis for denying reinstatement to the programs.
(c)Exceptions to paragraph (b)(1) of this section.
(1) If an enrollee of Part B of
(2) CMS will not pay an enrollee for items or services furnished by an excluded individual or entity, or under the medical direction or on the prescription of an excluded physician or other authorized individual more than 15 days after the date on the notice to the enrollee, or after the effective date of the exclusion, whichever is later.
(3) Unless the Secretary determines that the health and safety of beneficiaries receiving services under
(iii) Any health care items that are ordered by a practitioner, provider or supplier from an excluded manufacturer before the effective date of the exclusion and delivered within 30 days of the effective date of such exclusion. (For the period October 2, 1998, to October 4, 1999, payment may be made under
(4) CMS will not pay any claims submitted by, or for items or services ordered or prescribed by, an excluded provider for dates of service 15 days or more after the notice of the provider's exclusion was mailed to the supplier.
(i) Notwithstanding the other provisions of this section, payment may be made under
(ii) Notwithstanding paragraph (c)(5)(i) of this section, no claim for emergency items or services will be payable if such items or services were provided by an excluded individual who, through an employment, contractual or any other arrangement, routinely provides emergency health care items or services.
Title 42 published on 16-Nov-2018 03:48
The following are ALL rules, proposed rules, and notices (chronologically) published in the Federal Register relating to 42 CFR Part 1001 after this date.
- 42 CFR 1001.2006 — Notice to Others Regarding Exclusion.
- 42 CFR 1004.120 — Effect of an Exclusion on Program Payments and Services.
- 42 CFR 405.425 — Effects of Opting-Out of Medicare.
- 42 CFR 405.440 — Emergency and Urgent Care Services.
- 42 CFR 1003.1590 — Effect of Exclusion.
- 42 CFR 1002.6 — Payment Prohibitions.